Newaygo County GSRP Preschool Enrollment Application

Sibling(s)
Does this child have a sibling that attends a public school?

YesNo
Sibling School District*

Fremont Public SchoolsGrant Public SchoolsHesperia Community SchoolsNewaygo Public SchoolsWhite Cloud Public SchoolsOther
Please provide sibling(s) first and last names. First Name, Last Name.
This will ensure we properly connect family records in the county student information system.

Parent/Guardian Signature

Information on this application is confidential. Your child’s preschool program will not discriminate against any family on the basis of race, color, national origin, sex (including sexual orientation or sexual identity), disability, age, religion, height, weight, marital or family status, military status, ancestry, genetic information or any other legally protected category.
Certification of Provided Records*

I certify that the information, including income, provided in this application is accurate and truthful to the best of my knowledge. I understand that it is my responsibility to inform my child’s preschool program if I move, or if I have any other changes in circumstances that could affect my child’s enrollment or placement. I understand that by participating in the preschool program, my child’s learning and development will be assessed and monitored to support further growth; and that some results may be reported as scores and combined with other children’s scores for future research related to the general level of impact of kindergarten readiness across the county.
Certification of Confidentiality and Disclosure*

I understand that this information will be entered into a confidential central database system that may be accessed by Newaygo County RESA Great Start Readiness Programs in an effort to correctly place my child into a Newaygo County Preschool Program and effectively analyze Newaygo County services to families and children. My signature below constitutes consent to disclose the information in this application to the listed entities and obtain any relevant information from them.
Child Immunization Records and Health Appraisal*

I understand that I will be required to provide a current immunization record or appropriate waiver and health appraisal for my student in order to attend a preschool program. These can be provided at a later date. Failure to provide these documents may result in removal from programming.
Signature of Parent / Legal Guardian*

Clear
Type Name of Signatory*
Date*

MonthDayYear
Date
Should be Empty:

	First	Second	Third
Fremont Center - NC RESA Building Bridges
Fremont Pine - NC RESA Building Bridges
Huntey's Clubhouse Newaygo
Huntey's Clubhouse Hesperia
Newaygo Child Development Center Croton (NCDCC)

	First	Second	Third
Grant - NC RESA Building Bridges
Huntey's Clubhouse Hesperia
Huntey's Clubhouse Newaygo
Newaygo Child Development Center Croton (NCDCC)

	First	Second	Third
Hesperia - NC RESA Building Bridges
Huntey's Clubhouse Hesperia
Huntey's Clubhouse Newaygo
Newaygo Child Development Center Croton (NCDCC)

	First	Second	Third
Neway Nature Center - NC RESA Building Bridges
Huntey's Clubhouse Hesperia
Huntey's Clubhouse Newaygo
Newaygo Child Development Center Croton (NCDCC)

	First	Second	Third
White Cloud Center - NC RESA Building Bridges
Huntey's Clubhouse Hesperia
Huntey's Clubhouse Newaygo
Newaygo Child Development Center Croton (NCDCC)

Newaygo County Great Start Readiness Program (GSRP) Application

Child Information

Newaygo County GSRP Preschool

Family Information

Parent or Legal Guardian 1

Parent or Legal Guardian 2

Sibling(s)

Income of Family Members Legally Responsible for Child's Support

Supplemental Questions

Child (Applicant) Development Information

Other Confidential Information that may prioritize placement:

Parent/Guardian Signature